gastro Flashcards
investigations for diverticular disease
FBC → ↑WCC, ↑CRP, microcytic anaemia
Erect CXR → exclude pneumoperitoneum caused by perforation
Barium enema → sawtooth appearance of lumen (investigation of choice)
USS → assess bowel wall thickness, rule out other differentials
CT abdomen
Colonoscopy
indications for end ileostomy
permanent: panproctocolectomy for UC or FAP
temporary: emergency bowel resection for intra-abdominal sepsis, haemorrhage
indications for end colostomy
permanent: abdominoperineal resection for cancer involving anal sphincter
temporary: Hartmann’s (diverticulitis / bowel obstruction from cancer)
Hartmann’s procedure definition + indications
proctosigmoidectomy (rectosigmoid resection) → temporary end colostomy
emergency surgery when immediate anastomosis not possible for:
• Inflammation e.g. diverticulitis
• Colorectal cancer → obstruction / perforation
causes of abdominal distension
fat fluid: ascites fetus flatus: IBS, bowel obstruction faeces
causes of small bowel obstruction
adhesions
hernia
intra-abdominal masses e.g. lymphoma
causes of large bowel obstruction
colorectal cancer
volvulus
strictures e.g. from diverticular disease
bowel obstruction management
ABCDE
drip + suck (NBM + NGT decompression + IV fluids)
analgesia
definitive:
SBO → gastrograffin follow-through
laparotomy → bowel resection if: no prev abdo surg, strangulation, perforation, complete obstruction, irreducible hernia, peritonitis
indications for laparotomy in bowel obstruction
no prev abdo surg, strangulation, perforation, complete obstruction, irreducible hernia, peritonitis
SMA supplies which parts of bowel?
distal duodenum → splenic flexure
IMA supplies which parts of bowel?
splenic flexure → rectum
indications for loop ileostomy
anterior resection (rectosigmoid resection) + anastomosis for colon cancer / Crohn’s
indications for loop colostomy
relief of Sx of obstruction (no resection)
rare
Kocher’s incision: where + for what surg
L subcostal → open cholecystectomy
R subcostal → splenectomy / distal pancreatectomy
McBurney’s / Gridiron incision: where + for what surg
RIF (2/3 between umbilicus + ASIS) → open appendicectomy
indications for midline laparotomy
emergency: Hartmann’s (obstruction, perforation, trauma), ruptured AAA
elective: colectomy, vascular bypass, AAA repair
Mercedes Benz incision: where + for what surg
subcostal margins + midline → hepatobiliary surgery: liver transplant/resection, Whipple procedure (pancreatic cancer)
rooftop incision: where + for what surg
subcostal margins (similar to mercedes benz but w/o midline) → upper GI surg: oesophagectomy, gastrectomy
Rutherford Morrison / hockey stick / J-shaped incision: where + for what surg
LIF / RIF (more commonly L) → renal transplant
Pfannenstiel incision: where + for what surg
low transverse incision → gynaecological procedures: C-sections / lower urinary tract procedures: radical cystectomy / prostatectomy
flank incision for what surg
nephrectomy: renal cell carcinoma, PKD
inguinal incision for what surg
hernia repair
vertical incision = for vascular access
Lanz incision: where + for what surg
transverse @ McBurney’s point → open appendicectomy (reduced scarring)
stoma complications
immediate: operative complications (pain, infection, bleeding)
early: high output stoma, retraction, ischaemia/necrosis, parastomal abscess
late: parastomal hernia, prolapse, obstruction (strictures / stenosis)
causes of ascites
high albumin gradient (>11g/L): cirrhosis, portal HTN, cardiac failure
low albumin gradient (<11g/L): infection (peritonitis, TB), inflammation (nephrotic syn, pancreatitis), malignancy
causes of hepatomegaly
cirrhosis
malignancy: primary / mets
congestion: cardiac failure, constrictive pericarditis
infection: hepatitis
haematological: leukaemia, lymphoma, myeloproliferative disorders (sickle cell, myelofibrosis)
infiltration: sarcoidosis, amyloidosis, haemochromatosis
anterior resection: definition, indications, results in?
rectosigmoid resection
can be low or high
for rectal cancer not involving rectal sphincter
anorectal anastomosis (if healthy rectum) / temporary loop ileostomy / end colostomy
abdominoperineal resection: definition, indications, results in?
resection of sigmoid + rectum + anal sphincter
for malignancy involving anal sphincter
permanent end colostomy
panproctocolectomy: definition, indications, results in?
resection of entire colon + rectum
for UC / FAP
permanent end ileostomy / J pouch
complications IBD
toxic megacolon
malabsorption → gallstones, vit B12 deficiency
fistula, abcesses, strictures
malignancy: colon / PSC → cholangiocarcinoma
extra-abdominal signs IBD
derm: pyoderma gangrenosum, erythema nodosum, clubbing
eye: iritis, conjunctivitis
hepato-pancreato-biliary: gallstones, PSC → cholangiocarcinoma
histology in UC vs Crohn’s
ulcerative colitis: crypt abscesses
crohn’s: non-caesating granulomas
definition fistula
abnormal connection between two epithelial surfaces
definition hernia
protrusion of viscous / part of viscous through defect of its containing cavity into an abnormal position
indirect vs direct inguinal hernias
direct (20%) via Hesselbach’s triangle (weakness in posterior wall of inguinal canal)
↑intra-abdominal pressure
indirect (80%): through deep ring and out through superficial
patent processus vaginalis
complications more common
more difficult to reduce
differentiate: occlude deep ring + ask patient to cough
induction of remission ulcerative colitis
mild-mod: proctitis / proctosigmoiditis: rectal 5ASA after 4wks: + oral 5-ASA then add oral / rectal corticosteroid extensive: rectal 5ASA + oral 5ASA severe: admission IV corticosteroids \+ ciclosporin / consider surg
causes chronic liver disease
alcohol non-alcoholic fatty liver disease infection: hepatitis autoimmune: hepatitis, PSC, PBC vascular: Budd-Chiari, infiltrative: sarcoidosis, amyloidosis, haemochromatosis
causes of portal HTN
pre-hepatic: portal / splenic vein thrombosis
external compression (malignancy)
hepatic: cirrhosis (most common)
post-hepatic: budd-chiari, congestive heart failure, constrictive pericarditis
presentation portal HTN
ascites splenomegaly oesophageal varices (melaena, haematemesis) caput medusae worsening of haemorrhoids
management oesophageal varices
ABCDE IV fluids terlipressin (reduces portal pressure) endoscopic band ligation can treat portal HTN with TIPS (transjugular intrahepatic portosystemic shunt): hepatic to portal vein
management ascites
monitor weight
diuretics: spironolactone (+ furosemide if required)
fluid + salt restriction
therapeutic paracentesis (+ albumin infusion for large volume paracentesis)
TIPS (transjugular intrahepatic portosystemic shunt) for portal HTN
causes of splenomegaly
portal HTN
haem: leukaemia, lymphoma, myelofibrosis, haemolytic anaemia, sickle cell
infection: TB, malaria, HIV
inflammatory: Felty’s
definition + causes of massive splenomegaly
reaches midline / iliac crest / > 1500g CML myelofibrosis leishmaniasis malaria EBV
signs of decompensated liver disease
JAB:
jaundice
asterixes, ascites, altered consciousness (encephalopathy)
bruising
causes of dysphagia
obstruction: cancer, mallory-weiss tear
oesphageal dysmotility: achalasia, systemic sclerosis, stroke, MND, myaesthenia gravis
other: pharyngeal pouch
causes of tender hepatomegaly
hepatitis
rapid liver enlargement: budd-chiari, R heart failure
indications for splenectomy
emergency: rupture / trauma → uncontrolled bleeding
elective: haem (hypersplenism): ITP, TTP, AIHA, hereditary spherocytosis
oncological: leukaemia, lymphoma
causes of pancreatitis
most common: gallstones, alcohol trauma steroids mumps autoimmune scorpion bites hypercalcaemia ERCP drugs: furosemide, thiazides, azathioprine
scoring system for pancreatitis
glasgow score (severity) pao2 ↓ age > 55 neuts ↑ calcium ↓ renal function: ↑urea enzymes: AST, ALT, LDH albumin ↓ sugar: glucose ↑
signs on examination pancreatitis
epigastric tenderness grey-turner's sign: flank bruising cullen's sign: periumbilical bruising fox's sign: inguinal ligament bruising signs of hypocalcaemia: trousseau's (carpopedal spasm on BP cuff inflation) / chvostek's sign (facial nerve tap induces spasm)
investigations pancreatitis
bloods: FBC, CRP, U&Es, LFTs, amylase / lipase (normal in chronic), low Ca, faecal elastase reduced in chronic
imaging: abdo USS
AXR / erect CXR to rule out other causes
CT in chronic / diagnostic uncertainty for acute
ERCP: can remove gallstones
management acute pancreatitis
ABCDE
IV fluids + oxygen if low sats
analgesia
antiemetics
nutritional support: consider NGT + TPN, vitamin supplementation
treat cause: if gallstones cholecystectomy / ERCP if not fit for surgery
complications pancreatitis
acute: necrotising pancreatitis (high risk mortality) sepsis pseudocysts chronic: pseudocysts exocrine sufficiency + malabsorption diabetes pancreatic cancer
management chronic pancreatitis
cons: reduce alcohol
med: analgesia, creon, insulin for diabetes
surg: ERCP (sphincterotomy, stone extraction, stricture stenting) / cholecystectomy for gallstones
lateral pancreaticojejunal drainage
resection / opening of pancreatic duct
severity classification for diverticular disease
hinchley classification
- paracolonic abscess
- pelvic abscess
- purulent peritonitis
- faecal peritonitis
diverticular disease acute management
ABCDE IV fluids analgesia oral / IV ABx if diverticulitis surg: bleeding → colonscopy + endoscopic haemostasis (adrenaline injection, cauterisation) complications → Hartmann's
pathophysiology behind toxic megacolon
non-obstructive colonic dilatation due to myenteric plexus swelling (loss of bowel tone + motility)
gastrointestinal causes of clubbing
IBD
liver cirrhosis
coeliac disease
cancers: GI lymphoma, oesophageal carcinoma
causes of spider naevi
liver disease (>3)
pregnancy
COCP
prevention of oesophageal bleeding
propranolol
liver cirrhosis severity score
child-pugh
ulcerative colitis severity score
truelove + witt’s criteria:
mild: < 4 stools / day, some blood
mod: 4-6 stools / day, mod blood
severe: > 6 stools / day, systemic features (fever, high ESR, tachycardia)
maintenance Tx for ulcerative colitis
following mild-mod flare: rectal 5-ASA +/- oral 5-ASA
severe flare OR > 2 flares / year: oral azathioprine / mercaptopurine
maintenance Tx for Crohn’s
- azathioprine / mercaptopurine
2. methotrexate
induction of remission Crohn’s
- glucocorticoids (or 5-ASA or budesonide)
2. add azathioprine / mercaptopurine / methotrexate
features of peutz jeghers
autosomal dominant
pigmented freckling of lips, face, palms, soles
hamartous polyps in GIT
small bowel obstruction e.g. intususseption
increased risk of malignancy: colorectal, pancreatic, breast
causes budd-chiari
hepatic venous outflow obstruction
primary: hypercoagulable states (myeloproliferative, anti-phospholipid, COCP), stenosis
secondary: external compression (malignancy, trauma, abscess, cyst)
classification of intestinal ischaemia
- acute mesenteric ischaemia: SMA (distal duodenum → splenic flexure)
- chronic mesenteric ischaemia: all 3 gut arteries (SMA, IMA + coeliac trunk)
- ischaemic colitis: IMA (splenic flexure → rectum)
indications for liver transplant
liver failure due to: alcoholic / non-alcoholic liver disease viral hepatitis (chronic B+C) autoimmune hepatitis malignancy: HCC drug induced: paracetamol overdose budd-chiari infiltration: haemochromatosis, amyloidosis
complications liver transplant
immediate: pain, infection, bleeding, acute rejection
late: vascular / biliary anastomosic problems, immunosuppression (infection, malignancy)
types of liver transplant
- cadaveric (more common)
2. partial live donor transplantation (L / R lobe)
complications of liver disease
portal HTN
hepatocellular carcinoma
hepatic encephalopathy (toxins not removed from blood e.g. ammonia)
coagulopathy
management liver cirrhosis
supportive / symptomatic until liver transplant
cons: diet, reduce alcohol, avoid hepatotoxic drugs (e.g. NSAIDs), monitor for complications
med:
treat cause (e.g. protease inhibitors ± ribavirin for hep C)
treat symptoms / complications (e.g. diuretics, fluid restriction, tap for ascites)
severity scoring for cirrhosis
child-turcotte-pugh score encephalopathy ascites bilirubin albumin prothrombin time
severity scoring for cirrhosis
child-turcotte-pugh score encephalopathy ascites bilirubin albumin prothrombin time
types of gallstones
cholesterol (80%)
bilirubin
mixed
investigations gallstones
bloods: FBC, CRP, U+Es, LFTs
imaging: abdo USS (1st line)
ERCP if choledocholithiasis (common bile duct stone) → diagnostic + therapeutic
management gallstones
asymptomatic: observation
elective cholecystectomy if: gallstones > 3cm, porcelain gallbladder, gallstone in CBD
symptomatic (cholelithiasis): elective cholecystectomy
gallstone in CBD (choledocholithiasis): ERCP w biliary sphincterotomy + stone extraction OR cholecystectomy other surgical options: extra-corporeal shockwave lithotripsy biliary stent papillary balloon dilatation laparopscopic CBD exploration
complications gallstones
ascending cholangitis cholecystitis pancreatitis sepsis gallstone ileus
causes of jaundice
pre-hepatic: haemolysis (autoimmune, sickle cell. malaria), Gilbert’s
hepatic: viral hepatitis, alcohol, drugs (paracetamol, isoniazid, rifampicin)
post-hepatic: obstructive (gallstones, pancreatic cancer)
PBC vs PSC (aetiology)
PBC: autoimmune damage (AMA +ve) to intrahepatic bile ducts → cholestasis
PSC: fibrosis → stenosis of bile ducts (intra + extrahepatic) → cholestasis
complications of PBC
liver cirrhosis + failure
osteomalacia + osteoporosis
risk of hepatocellular carcinoma
PBC associations
autoimmune conditions:
rheumatoid, systemic sclerosis, sjogren’s
thyroid disease
complications of PSC
liver cirrhosis + failure
risk of cholangiocarcinoma + colorectal carcinoma
PSC associations
IBD esp ulcerative colitis
HIV
definition of achalasia
- oesophageal aperistalsis
- failure of relaxation of lower oesophageal sphincter
due to loss of ganglion cells in myenteric plexus
presentation of achalasia
dysphagia (fluid + solids) posturing to aid swallowing regurgitation (+ cough + risk of aspiration pneumonia) retrosternal pain / pressure weight loss
how does a lateral pancreaticojejunostomy work
jejunum divided and proximal end anastomosed to pancreas to allow drainage
jejuno-jejunostomy restores continuity of GI tract
differentiating Sx of small + large bowel obstruction
SBO: early vomiting, late constipation, high-pitched tinkling bowel sounds, central more frequent abdo pain
LBO: late vomiting, early constipation, lower less frequent abdo pain, empty rectum on PR
definitive management of volvulus
caecal volvulus: usually requires surgery (R hemicolectomy)
sigmoid volvulus: decompression w rigid sigmoidoscopy + rectal tube insertion
typical presentation acute cholangitis
charcot's triad: 1. fever 2. RUQ pain (radiating to back) 3. jaundice (+ itching, pale stools, dark urine) raynaud's pentad: 4. hypotension 5. confusion
management acute cholangitis
ABCDE IV fluids + analgesia + anti-emetics broad-spectrum ABx definitive: therapeutic ERCP after 24-48hrs (to relieve obstruction) other options: shockwave lithotripsy cholecystectomy
types of hiatus hernia
- sliding: Z-line moves above diaphragm
2. rolling: fundus of stomach herniates above diaphragm w Z-line maintined below
types of oesophageal carcinoma
upper 2/3: squamous cell carcinoma
lower 1/3: adenocarcinoma
management achalasia
medical: CCBs, nitrates (isosorbide dinitrate)
surgical:
pneumatic (balloon) dilatation (older pts)
Heller cardiomyotomy (laparoscopic incision of LOS muscle, younger pts)
2nd line: endoscopic botox injection
last line: gastrostomy
types of autoimmune hepatitis
type I: most common
anti-SMA (smooth muscle), ANA (anti-nuclear Ab)
type II: ALKM1-Ab (anti-liver/kidney microsomal type 1), younger pts w other autoimmune conditions
type III: soluble liver-kidney Ag, older pts
complications coeliac disease
dermatitis herpetiformis malabsorption: folate / B12 / iron deficiency vitamin D deficiency → osteomalacia malignancy: small-bowel cancer, EATL hyposplenism
DDx RUQ pain
duodenal ulcer
hepatitis, liver abscess
gallstones, cholangitis, cholecystitis
DDx LUQ pain
splenic rupture / infarct
DDx epigastric pain
GORD
gastric ulcer
pancreatitis
DDx umbilical pain
early appendicitis
ruptured AAA
IBD
DDx hypochondrial pain
renal colic
pyelonephritis
hydronephrosis
DDx RLQ pain
IBD
late appendicitis
gynae: ectopic pregnancy, ovarian cyst / torsion
DDx LLQ pain
diverticulitis
IBD
faecal impaction
gynae: ectopic pregnancy, ovarian cyst / torsion
DDx suprapubic pain
cystitis
UTI
urinary retention
investigations liver cirrhosis
bloods: FBC, CRP, LFTs, U&Es, clotting, hepatitis serology, aFP (for HCC)
diagnostic:
fibroscan (transient elastography): best
acoustic radiation force impulse imaging
liver biopsy
monitor for complications:
USS / CT / MRI
OGD → varices
tumour markers cholangiocarcinoma
CEA
Ca19-9
Ca125
presentation budd-chiari
RUQ pain jaundice portal HTN ascites hepatomegaly leg oedema (IVC obstruction)
management budd-chiari
asymptomatic / Sx onset > 72 hours: anticoagulation (LMWH/heparin + warfarin)
Sx onset < 72 hours: thrombolysis
Treat ascites
Surgical:
Angioplasty of hepatic vein + IVC
Transjugular intrahepatic portosystemic shunt
